The Donabedian model of measuring quality identifies all of the following as main types of improvements EXCEPT:
The Donabedian model of measuring quality identifies three main types of improvements: changes to structure, process, and outcome (Fig. below).
Donabedian model for measuring quality.
The most common delayed complication following carotid endarterectomy is:
Complications of carotid endarterectomy include central or regional neurologic deficits or bleeding with an expanding neck hematoma. An acute change in mental status or the presence of localized neurologic deficit requires an immediate return to the operating room (OR). An expanding hematoma may warrant emergent airway intubation and subsequent transfer to the OR for control of hemorrhage. Intraoperative anticoagulation with heparin during carotid surgery makes bleeding a postoperative risk. Other complications include arteriovenous fistulae, pseudoaneurysms, and infection, all of which are treated surgically. Intraoperative hypotension during manipulation of the carotid bifurcation can occur and is related to increased tone from baroreceptors that reflexly cause bradycardia. Should hypotension occur when manipulating the carotid bifurcation, an injection of 1% lidocaine solution around this structure should attenuate this reflexive response. The most common delayed complication following carotid endarterectomy remains myocardial infarction. The possibility of a postoperative myocardial infarction should be considered a cause oflabile blood pressure and arrhythmias in high-risk patients.
The most appropriate treatment for a seroma after a soft-tissue biopsy is:
Lymph node biopsies have direct and indirect complications that include bleeding, infection, lymph leakage, and seromas. Measures to prevent direct complications include proper surgical hemostasis, proper skin preparation, and a single preoperative dose of antibiotic to cover skin flora 30 to 60 minutes before incision. Bleeding at a biopsy site usually can be controlled with direct pressure. Infection at a biopsy site will appear 5 to 10 days postoperatively and may require opening of the wound to drain the infection. Seromas or lymphatic leaks resolve with aspiration of seromas and the application of pressure dressings, but may require repeated treatments or even placement of a vacuum drain.
Prophylaxis using low-dose unfractionated heparin reduces the incidence of fatal pulmonary embolisms (PE) by:
Deep vein thrombosis (DVT) occurs after approximately 25% of all major surgical procedures performed without prophylaxis, and pulmonary embolism (PE) occurs after 7%. Despite the well-established efficacy and safety of preventive measures, studies show that prophylaxis often is underused or used inappropriately. Both low-dose unfractionated heparin and low-molecular-weight heparin have similar efficacy in DVT and PE prevention. Prophylaxis using low-dose unfractionated heparin has been shown to reduce the incidence of fatal PEs by 50%.
Which of the following is the best test to predict successful extubation of a patient?
Protocol-driven ventilator weaning strategies are successful and have become part of the standard of care. The use of a weaning protocol for patients on mechanical ventilation greater than 48 hours reduces the incidence of ventilator-associated pneumonia (VAP) and the overall length of time on mechanical ventilation. Unfortunately, there is still no reliable way of predicting which patient will be successfully extubated after a weaning program, and the decision for extubation is based on a combination of clinical parameters and measured pulmonary mechanics. The Tobin index (frequency [breaths per minute]/ tidal volume [L] ), also known as the rapid shallow breathing index, is perhaps the best negative predictive instrument. If the result equals less than 105, then there is nearly a 70% chance the patient will pass extubation. If the score is greater than 105, the patient has an approximately 80% chance of failing extubation. Other parameters such as the negative inspiratory force, minute ventilation, and respiratory rate are used, but individually have no better predictive value than the rapid shallow breathing index.
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